Failure to Report and Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to implement its abuse policy and procedure regarding the reporting and investigation of an injury of unknown source for a dependent resident. The resident, who was severely cognitively impaired, non-ambulatory, and required a mechanical lift for all transfers, sustained acute fractures to both the left and right tibia and fibula. Despite the facility's policy requiring immediate reporting of injuries of unknown source to the state agency and a thorough investigation, no initial allegation report or 5-day investigation report was completed or submitted. The policy also required that all injuries of unknown source, especially those involving serious bodily injury, be reported within two hours of discovery. Upon discovery of the fractures, the DON and ADON interviewed staff and found no reports of falls or trauma, and the Medical Director, after reviewing the resident's medical record, determined the fractures were pathological due to the resident's history of osteoporosis and previous fractures. However, the Medical Director did not review the emergency department or hospital records and was unaware of the bilateral nature of the fractures. The administrator confirmed that, based on the determination of pathological fractures, the facility did not report the incident or conduct the required investigation, despite the policy's stipulations for injuries of unknown source.